Summary Structurally, the sacrumecoccyx provides the dual roles of serving as the base ofthe spinal column while also forming part of the pelvic ring. Physiological movement control ofthe pelvis and the spine are functionally interdependent. In particular, intra-pelvic control,(that between the ilia and sacrum/coccyx in support and control of the forces and small movements within the pelvic ring) is fundamental to controlling its spatial organization as a wholeand its control on the femoral heads, all of which directly influence spinal alignment andcontrol mechanisms. This involves coordinated activity in the related neuro-myofascialsystems in providing mechanisms of both intrinsic and extrinsic support and control. 2010 Elsevier Ltd. All rights reserved.

Janda proposed the concept of the Pelvic Crossed

Syndrome as an underlying factor in the genesis andperpetuation of many low back pain syndromes (Janda,1987; Janda and Schmid, 1987; Janda et al., 2007). Here,imbalanced muscle activity e tightness and overactivity ofthe hip flexors and low back extensors and a coexistentunderactivity in the abdominals and glutei create a crossedpattern of disturbed sagittal lumbopelvic posturo-

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movement alignment and control. While certainly evident

in back pain populations, for the observant clinician it is nota universal finding.Like Janda, our group has been interested in the validityof clinical pattern recognition which appears to alsodelineate another different, yet broad subgroup within theback pain population who share in common similar featuresof changed postural alignment and control. This sub-groupdisplays a relative hyperactivity in the upper abdominalwall and piriformis/hamstrings with underactivity in thelower abdominals, deep hip flexors and low back extensors.This also creates an altered crossed pattern affecting

PREVENTION & REHABILITATIONePOSTURAL PHYSIOLOGY

The Pelvic Crossed Syndromes: A reflection of

imbalanced function in the myofascial envelope;a further exploration of Jandas work

PREVENTION & REHABILITATIONePOSTURAL PHYSIOLOGY

300sagittal lumbopelvic alignment and control and has beendescribed by Key et al. (2008b).It is clinically apparent that most patients presentingwith low back and pelvic pain syndromes display at leastsome of the features attributable to either of these twoprimary pictures of altered pelvic function. In Janda soriginally proposed Pelvic Crossed Syndrome, the pelvis ismore posterior and this is associated with imbalancedcoactivation of the trunk muscles with more dominantactivity observed in the extensors. Key et al. (2008b)proposed this syndrome be re-termed the Posterior PelvicCrossed Syndrome (Figure 1C). Conversely, in the otherbroad group, the pelvis is postured more anteriorly and thisis associated with a predominant tendency to more axialflexor activity e described by Key et al. (2008b) as theAnterior Pelvic Crossed Syndrome (Figure 1B).However, it is important for the clinician to also recognise that underpinning both primary pictures of pelvicposturo-movement dysfunction there is usually a related,common and clinically apparent fundamental deficit in theintegrated and balanced control provided from the deep,innermost myofascial sleeve which sub-serves the foundations of lumbopelvic support and control.Key et al. (2008a) proposed that the muscles of the bodycould for practical purposes be conceptually viewed asessentially consisting of two systems e a deep anda superficial systemic muscle system. They termed thedeep system the Systemic Local Muscle System andproposed that this plays a critical role in underlyingpostural support and control.It is hereby further proposed that in respect to healthylumbopelvic function, an important part of this deepsystem is a continuous, largely internal three dimensionalmyofascial web, providing a scaffold of tensile inner

J. Keysupport and stability and contributing to a structural andfunctional bridge between the lower torso and legs. It issuggested that these collective myofascial aggregations betermed the Lower Pelvic Unit (LPU). This includes theobvious contractile elements for which there is accumulating evidence of deficient function in subjects with lowback and/or pelvic pain e the transversus abdominus(Hodges and Richardson, 1996, 1998, 1999) multifidus(Hides et al., 1996) the diaphragm and pelvic floor muscles(OSullivan et al., 2002; Hodges, 2006). Impressions fromclinical practice suggest inclusion also of the obturators,iliacus, psoas, and all their related and interconnectingfascial sheaths. Sound activity within this myofascial innerstocking sustains many functional roles: e providing deepanterior support to the lower half of the spinal column;with the spinal intrinsics it contributes to lumbopelviccontrol (Hodges, 2004); while also contributing to thegeneration of IAP (Cresswell et al., 1994), continence andrespiration (Hodges and Gandevia 2000) (Figure 2).Importantly, it is further asserted that from a therapeutic perspective, co-operative activity within the LPUallows the modulation of discrete yet clinically apparent,fundamentally important intra-pelvic movements andspatial shifts. In helping to control our posturo-movements,it acts as the collective internal agonist to balance theactions and forces created by activity of the outer antagonists. This balanced coactivation within the LPU andbetween it and the large more superficial muscles providescontrol of the myo-mechanics and movement force couplesnecessary to allow the pelvis to be the initiator and driverof functional posturo-movement control of the torso on thelegs. Control initiated from the base of the spine throughthe pelvis, directed via the ischia and coccyx, is essential inbeing able to effectively manage the delicate neuromuscular balance involved in being upright againstgravity. It also enables one to draw upon on an endlessarray of options in the fluid control of movement includingbeing able to create kinematically sound patterns ofmovement which support basic activities of daily living ebending over, lifting, reaching squatting, jumping and so one all possible when the pelvis can act in its prime role asthe centre of weight shift in the body. Balanced coactivation from the LPU provides internal stability to thepelvis as it swings and swivels on the femoral heads which isnecessary in weight shift, load transfer and in controllingequilibrium. This is core control.

Clinical relevance

Figure 1 Altered control of pelvic position changes the

alignment and control mechanisms throughout the spine.Reproduced from Back pain: A movement problem by Key,publishing early 2010. With permission from Elsevier.

The experienced clinician knows that seemingly subtle

changes and differences in pelvic posturo-movementcontrol can mean a lot in the presenting symptom pictureof those with spinal pain and related disorders. Appreciation of the Pelvic Crossed Syndromes and the commonassociated dysfunction in the LPU helps the practitioner tosee and better understand what is driving the patientsunderlying problem and the likely needs in terms ofretraining appropriate functional motor control. In theauthors clinical experience, this is best addressed in thepatient initially relearning specific activation of deficientelements within the LPU, establishing the importantfundamental patterns of intra-pelvic control and

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Figure 2 Much of the LPU involves a prevertebral and intra-pelvic myofascial web of support. Reproduced from Back pain: Amovement problem by Key, publishing early 2010. With permission from Elsevier.

integrating these into basic functional patterns of movement control initiated from the pelvis. This will betterensure the likelihood of the patient achieving more functionally appropriate and real core control.